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Temporary Bridge Plating vs Primary Arthrodesis of the First Tarsometatarsal Joint in Lisfranc Injuries: Randomized Controlled Trial.

ABSTRACT: BACKGROUND:Unstable Lisfranc injuries are best treated with anatomic reduction and stable fixation. There are controversies regarding which type of stabilization is best. In the present study, we compared primary arthrodesis of the first tarsometatarsal (TMT) joint to temporary bridge plating in unstable Lisfranc injuries. METHODS:Forty-eight patients with Lisfranc injuries were included and followed for 2 years. Twenty-four patients were randomized to primary arthrodesis (PA) of the medial 3 TMT joints, whereas 24 patients were randomized to temporary bridge plate (BP) over the first TMT joint and primary arthrodesis of the second and third TMT joints. The main outcome parameter was the American Orthopaedic Foot & Ankle Society (AOFAS) midfoot scale and the secondary outcome parameters were the 36-Item Short Form Health Survey (SF-36) and visual analog scale for pain (VAS pain). Computed tomography (CT) scans pre- and postoperatively were obtained. Radiographs were obtained at follow-ups. Pedobarographic examination was performed at the 2-year follow-up. Twenty-two of 24 patients in the PA and 23/24 in the BP group completed the 2-year follow-up. RESULTS:The mean AOFAS midfoot score 2 years postoperatively was 89 (SD 9) in the PA group and 85 (SD 15) in the BP group (P = .32). There were no significant differences between the groups with regard to SF-36 or VAS pain scores. The alignment of the first metatarsal was better in the BP group than in the PA group measured by the anteroposterior Meary angle (P = .04). The PA group had a reduced peak pressure under the fifth metatarsal (P = .047). In the BP group, 11/24 patients had radiologic signs of osteoarthritis in the first TMT joint. CONCLUSION:Both treatment groups had good outcome scores. The first metatarsal was better aligned in the BP group; however, there was a high incidence of radiographic osteoarthritis in this group. LEVEL OF EVIDENCE:Therapeutic level I, prospective randomized controlled study.

SUBMITTER: Stodle AH

PROVIDER: S-EPMC7406968 | biostudies-literature | 2020 Aug

REPOSITORIES: biostudies-literature

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Temporary Bridge Plating vs Primary Arthrodesis of the First Tarsometatarsal Joint in Lisfranc Injuries: Randomized Controlled Trial.

Stødle Are H AH Hvaal Kjetil H KH Brøgger Helga M HM Madsen Jan Erik JE Husebye Elisabeth Ellingsen EE

Foot & ankle international 20200605 8

<h4>Background</h4>Unstable Lisfranc injuries are best treated with anatomic reduction and stable fixation. There are controversies regarding which type of stabilization is best. In the present study, we compared primary arthrodesis of the first tarsometatarsal (TMT) joint to temporary bridge plating in unstable Lisfranc injuries.<h4>Methods</h4>Forty-eight patients with Lisfranc injuries were included and followed for 2 years. Twenty-four patients were randomized to primary arthrodesis (PA) of ...[more]

PMID: 32501109

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Project description:BackgroundTraditionally, a lengthy period of nonweightbearing is required following arthrodesis of the first tarsometatarsal (TMT) joint in order to provide a stable healing environment for the bones. The goal of this research was to determine the resistance to plantar gapping of 2 locked intramedullary devices and a medial plate with crossing screw, all specifically designed for hallux valgus correction, and compare them to traditional 2-crossing screw fixation under a cyclic testing protocol. We hypothesized the locked intramedullary devices and the medial plate with crossing screw would better resist plantar gapping.MethodsForty cadaver specimens received 1 of 4 operative treatments: a locked intramedullary device with 2 points of fixation in the cuneiform, a locked intramedullary device with 1 point of fixation in the cuneiform, a medial plate with crossing screw, or 2 crossing screws. We applied dorsiflexion bending forces to the first TMT joint using a cadaveric fatigue model for 20 000 cycles. The plantar gap between the metatarsal and cuneiform was measured at the beginning and end of cyclic testing. Thirty-six specimens were included in the final data set.ResultsBoth locked intramedullary device groups and the medial plate with crossing screw group exhibited significantly less gap widening compared to the 2-crossing screw group (vs 3-hole intramedullary device, P = .014; vs 4-hole intramedullary device, P = .010; and vs medial plate with crossing screw, P = .044). The intramedullary device groups were the most stable during the cyclic fatigue test, exhibiting the smallest gap widening. The medial plate with crossing screw fixation was also more stable than crossing screws in the cyclic fatigue model.ConclusionsThe locked intramedullary devices and medial plate with crossing screw resisted plantar gapping better than 2 crossing screws when used for first TMT arthrodesis.Clinical relevanceThese results indicate that locked intramedullary devices and medial plates with crossing screws may promote superior bone healing and may better tolerate early weightbearing compared with 2 crossing screws.

Project description:BACKGROUND:Lisfranc injuries are known to be rare and often overlooked injuries that can cause long-term disability and pain when missed or treated incorrectly. The wide variety of Lisfranc injuries ranges from subtle ligament distensions to open fracture dislocations. The treatment of Lisfranc joint injuries is still controversial and very little is known about what types of injury can be treated nonoperatively. The current literature provides only two randomized studies on dislocated Lisfranc injuries. These studies have shown that primary arthrodesis (PA) leads to a similar or better outcome and results in fewer secondary operations when compared with open reduction and internal fixation (ORIF) in ligamentous injuries. There have been no previous randomized studies of the nonoperative versus operative treatment of Lisfranc injuries. Therefore, the purpose of this study is to compare the operative and nonoperative treatment of non-dislocated Lisfranc injuries and to compare the ORIF and PA treatment of dislocated Lisfranc injuries. METHODS:This study is a prospective, randomized, national multi-center trial. The trial comprises two strata: Stratum I compares cast-immobilization versus open reduction and internal fixation (ORIF) treatment of non-dislocated Lisfranc joint injuries. Stratum II compares PA versus ORIF in the treatment of dislocated injuries of the Lisfranc joint. The main hypothesis of stratum I is that the nonoperative treatment of non-dislocated Lisfranc injuries achieves a similar outcome compared with operative treatment (ORIF). The hypothesis of stratum II is that PA of dislocated Lisfranc injuries yields a similar functional outcome compared with ORIF, but that PA results in fewer secondary operations than ORIF. The main outcome measure is the American Orthopaedic Foot and Ankle Society (AOFAS) Midfoot score and the secondary outcome measures are Visual-Analogue-Scale Foot and Ankle (VAS-FA), Visual-Analogue-Scale (VAS), rate of secondary operations and other treatment-related complications. The results will be analyzed after the 2-year follow-up period. DISCUSSION:This publication presents a prospective, randomized, national multi-center trial study protocol. It provides details of patient flow, randomization, aftercare and methods of analysis of the material and ways to present and publish the results. TRIAL REGISTRATION:ClinicalTrials.gov identifier: NCT02953067 24.10.2016.

Project description:BackgroundFirst tarsometatarsal joint (TMT-1) hypermobility might cause hallux valgus deformity (HV), and recurrence following surgical correction. Anatomic findings, indicating tibialis anterior tendon (TAT) involvement in TMT‑1 stabilization, led to the development of cross-glide test allowing clinical TMT‑1 stability testing. Cross-glide test function was evaluated in anatomical specimens and in the clinical setting, compared to simulated weight-bearing computer tomography (CT) analysis.MethodsCross-glide test was evaluated in 6 healthy lower leg specimens before and after TAT transection. Clinical testing was performed prospectively in 36 feet (6 controls, 21 HV, 9 recurrent HV); consecutive weight-bearing CT analysis was performed. Results from clinical testing were compared to CT analysis.ResultsTMT‑1 instability significantly increased in anatomic specimens following TAT transection (p = 0.009). In the clinical setting, all healthy feet were cross-glide test negative, 62% of HV cases and all recurrent HV feet were positive. In the CT analysis- Compared to controls the HV cases revealed significantly increased MT‑1 internal rotation (p = 0.003) and decreased dorsal angle (p = 0.002), considered as collapsing forefoot signs; HV recurrent cases revealed similar results. Positive cross-glide tested cases revealed increased MT‑1 internal rotation values (p < 0.001) and dorsal angle values (p < 0.001) in CT analysis. Strikingly, cross-glide test positive HV cases revealed significantly increased internal TMT‑1 rotation (p = 0.043) in CT analysis, and HV and IMT (intermetatarsal) angle were significantly higher (p = 0.005, p = 0.006). 15 HV recurrence cases, treated with TMT‑1 arthrodesis, revealed no recurrence during follow-up.ConclusionCross-glide test allows reliable clinical TMT‑1 instability testing, via TAT tension, and is less laborious than CT analysis. We recommend TMT‑1 arthrodesis in cases with instability in clinical testing, to avoid HV recurrence.

Dataset Information

Temporary Bridge Plating vs Primary Arthrodesis of the First Tarsometatarsal Joint in Lisfranc Injuries: Randomized Controlled Trial.

Publications

Temporary Bridge Plating vs Primary Arthrodesis of the First Tarsometatarsal Joint in Lisfranc Injuries: Randomized Controlled Trial.

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